The study of trauma is inherently political. It is hard for psychiatrists to maintain an open mind, to respect and tolerate uncertainty and to maintain standards of scrutiny of scientific data when there are powerful political and emotional pressures to take up a polarised view of recovered memories of child sexual abuse. The two polarisations that have arisen are of recovered memories as invariably historically accurate versus recovered memories as invariably false and created by suggestion by clinicians. Current evidence suggests the psychiatrist should take up a cautious position somewhere between these two poles.

There can be few more agonising experiences than being falsely accused of having sexually abused one's child – except perhaps to be told that one's long-standing memories of childhood abuse are an example of false memory syndrome. People have been profoundly hurt both by false accusations of abuse and by false denials and dismissals of memories of abuse. Both of these can happen.

The present case study describes a typically complex clinical presentation of chronic post-traumatic stress disorder (PTSD) suffered by a Second World War veteran and advises on multi-disciplinary out-patient management extending to acute hospital care. Limited symptomatic impact of psychological and psychopharmacological therapies is discussed, and related to patient reports of satisfaction with therapeutic outcome.

In my view Dr Mollon fails to achieve the balance he is seeking and at times appears to take a partisan position.

The goal of psychoanalytic psychotherapy with a distressed child is to alter the child's psychic structure and function. The technique is based on the same theory as adult psychoanalytic psychotherapy (see Box 1). The unconscious is central, as is the interpretation of defence, resistance, transference, working through and the reconstruction of earlier life. It differs from adult psychotherapy in that the child's age and level of development are at all times central to the work. In young children the focus of interpretation is on free play, while with adults it is free association of ideas. In the treatment of adolescents a combination of techniques, both adult and pre-adolescent, are used, while for late adolescents the technique is basically adult technique with attention to issues relevant to that stage of the life cycle.

It is a sobering fact that the average age of the surviving veterans of the Second World War is now close to 80 years. The available information indicates that the prevalence of post-traumatic stress disorder (PTSD) in all Second World War veterans is slightly higher than the 15% lifetime prevalence found in Vietnam War veterans, although there are few reliable studies on which to base this conclusion. It is, however, consistent with the finding that combat stress, based on casualty rates, during periods of the Vietnam War was equivalent to the severity of combat stress in the Second World War. There are several epidemiological studies (Beebe, 1975; Tennant et al, 1986) of more specific Second World War veteran groups such as Far East prisoners of war and, predictably, they show higher PTSD prevalence rates, ranging between 30 and 50%.

Whenever colleagues meet it seems there is discussion about the latest inquiry into suicides or homicides. One cannot turn on the television without the news or a documentary referring to the latest tragedy. Risk assessment and defensible documentation are commonly the subjects of lectures and symposia. Lessons are learned, or not, from published inquiries and associated media attention. The attribution of blame is always high on the agenda. Yet when visiting psychiatric services and talking to staff I am usually impressed by their professionalism and staggered by their workload.

Abuse is an inter-generational problem. Abusers have been damaged in childhood by abusive action perpetrated on them, usually by their parents but sometimes by other significant adults. At times, in becoming adults, the early emotional damage can manifest into psychopathological features, including perversions or paraphilias and perpetration of abuse against children.

In 1899, Maudsley wrote:

Recent research confirms that a range of psychological problems and psychiatric disorders are common in people with diabetes. Such problems are important not only because of the suffering caused, but also because of their impact upon the management and outcome of the diabetes itself. This article reviews the psychosocial impact of diabetes and its treatment, describes the range of psychological problems and psychiatric disorders which commonly occur in people with diabetes, and outlines the role of the psychiatrist in the recognition and management of these clinical problems.

Despite the frequency with which psychiatric emergencies are encountered in medical and other services, the literature, at least in the UK, is relatively sparse, with little systematic research on either service provision or areas of clinical interest. Services have often evolved in an ad hoc way and psychiatric emergencies are often seen by very junior trainees early in their psychiatric careers, with little relevant training. Although the vigilance of the Royal College of Psychiatrists on its approval visits has ensured that most trainees are given advice on the recognition and management of violence (at induction courses at the start of their training), it is not uncommon to find that wider areas of training in emergency psychiatry are neglected. It is still the case, for example, that some postgraduate programmes in psychiatry provide little or no formal training on emergency psychiatry.

From the 1991 census (Office of Population Censuses and Surveys, 1993) it is estimated that 5.9% of the total population of England and Wales belong to an ethnic minority, and that 3% of this ethnic minority population are aged 65 years and older. This compares with 17% aged 65 years and older in the indigenous population. Although the numbers of elderly people from ethnic minorities are small in absolute terms, these groups are growing rapidly, and mental health professionals working with elderly patients will increasingly need to be equipped with the necessary services and skills to meet their specific needs. The elderly ethnic minority population of the UK is extremely diverse; the largest groups originate from the Indian subcontinent and the Caribbean, but there are also significant communities of Chinese, Somali, Vietnamese, Eastern European, Mediterranean and Irish origin, all of which require consideration when planning and providing services, whatever their numbers. This diversity is also important when considering the various factors that influence the presentation and diagnosis of mental disorders in these groups.

Guidelines are statements which help people to decide what to do. Familiar examples include the Highway Code, or the ‘How to Prepare’ instructions on a jar of coffee. Traditionally, clinicians have sought knowledge from their senior colleagues, tutors and mentors, textbooks and published articles. They will continue to do so. However, there has been a recent surge of interest in guidelines on specific clinical topics. This has been driven by interest in unexplained variation in patterns of care, concern that some care is inappropriate, and the growing demand for routine, clinically effective practice. Because clinicians have limited time and resources, it can be helpful to summarise evidence for effectiveness where it is available and provide it in a concise format (see Box 1).

This paper examines the complex relationship between the process of investigation and the provision of treatment in cases of child sexual abuse. Child sexual abuse is now a well-recognised and documented phenomenon, the deleterious sequelae of which have been studied, initially in survivors presenting in adulthood (Wyatt & Powell, 1989) and (more recently) during childhood (Briere, 1992; Kendall-Tackett et al, 1993). Following the recognition of sexual abuse from the accounts of adult survivors, and in order to reduce the harm caused to sexually abused children by providing earlier protection and treatment, attention began to be directed to the earlier recognition of child sexual abuse, during childhood.

There is now a greater awareness among academics that teaching skills, like clinical and research skills, must be acquired and practised, usually over an extended period of time. In addition, teachers have a great responsibility in ensuring that medical students develop the knowledge, skills and attitudes to enable them to become competent and effective doctors. Although teaching theory is complex, attention to a few simple techniques and careful planning of teaching sessions and courses can greatly improve the experience for both students and teachers. This article discusses some of the theoretical aspects of teaching medical students and is followed by three articles which specifically address the teaching of child and adolescent, general and old age psychiatry to medical undergraduates.

The term ‘epilepsy’ refers to a tendency to have recurrent seizures. Epileptic seizures arise from an imbalance of excitatory and inhibitory cerebral neurotransmitters associated with sudden, paroxysmal, synchronous and repetitive discharges of neurones. All normal brains have the capability to have seizures. Epileptic seizures arise where there is lowering of the naturally occurring seizure threshold. Excitotoxins such as glutamate released in the brain during seizures can cause irreversible cell damage. Young children are especially vulnerable. Prolonged seizures (greater than 30 minutes) in children correlate with subsequent learning disability.

There is a myth that people with mental disorders comply poorly with treatment. In fact, psychiatric patients are no more likely than patients in other medical specialities to go against the advice of their doctor. However, it is easy to find instances where psychotropic medication is refused by the supposed beneficiary. The value of neuroleptic treatment in schizophrenia is now widely accepted, and failure to take such treatment is associated with relapse. Relapse may endanger the patient and other people. Despite this, people with schizophrenia frequently fail to take their treatment. One-third of patients leaving a general adult psychiatry ward can be expected to be non-compliant within two years (Buchanan, 1992).

The experience of sexual abuse in childhood is very common (Jehu, 1988). The highest estimate from the USA (Wyatt & Peters, 1986) suggests that 42% of girls up to the age of 17 have experienced abuse, and the best estimate from Britain (Baker & Duncan, 1985) would give a prevalence of between 12 and 20%. Mullen et al (1993) found in a general population of women in New Zealand an overall prevalence of abuse before the age of 16 of 32%, with 20% reporting genital contact and 3% penetrative sex. In the American series half of those abused (21% of the respondents) reported that the abuse was by a family member: the figure for intra-familial abuse in the British series was 14% of those reporting abuse, and thus about 3–5% of all the women who responded. There may be many explanations for the large international variations, including differences in definition, sampling and other aspects of methodology, but it is also possible that abuse is indeed more common in some countries than others.

The aim of this article is to set the teaching of child and adolescent psychiatry to medical undergraduates in the framework of current educational theory and General Medical Council (1993) curriculum guidelines. The objectives are to:

(a) outline the main reasons for teaching child and adolescent psychiatry in the medical undergraduate curriculum;

(b) discuss placement of child and adolescent psychiatry teaching in the curriculum;

(c) outline relevant content;

(d) describe appropriate teaching methods; and

(e) describe assessment and evaluation procedures.

The Government white paper ‘Health of the Nation’ set a target for reduction of suicide rates by 15% by the year 2000. Although the document did not make specific reference to adolescence, it is no less important an issue in this age group than in adulthood since, along with accidental death and malignancy, suicide is one of the most common causes of death in late adolescence and early adulthood and there is an upward trend (Diekstra, 1993; McClure, 1994; Diekstra et al, 1995). How the reduction should be achieved is not clear, since suicide is a rare event which is the culmination of complex processes, and present knowledge does not give a firm foundation for evidence-based practice (Gunnell & Frankel, 1994).